Urology Flashcards
Causes of scrotal swelling
Painless: Hernia Hydrocele Varicocele Idiopathic scrotal oedema Testicular tumours (rare)
Painful: Testicular torsion Torsion of testicular appendage Epididymitis Orchitis Zipper entrapment Henoch-Schonlein purpura Allergic reactions Insect bites Injuries
Inguinal hernia
Cannot get above it on examination
Cough impulse may be present
May be reducible
Testicular tumours
Discrete testicular nodule May have associated hydrocele Symptoms of metastatic disease USS scrotum AFP and B-HCG
Acute epididymo-orchitis
History of dysuria and urethral discharge
Swelling may be tender and eased by elevated testis
Most cases due to Chlamydia
Epididymal cysts
Single or multiple cysts
May contain clear or opalescent fluid (spermatocele)
Usually occur over 40 years of age
Painless
Lie above and behind testis
Usually possible to get above lump on examination
Hydrocele (communicating)
Non-painful, soft fluctuant swelling Get above it on examination Clear fluid Transilluminate Feature of testicular cancer Due to patent processus vaginalis
Testicular torsion
Severe, sudden onset testicular pain
Risk factors: abnormal testicular lie
Typically affects adolescents and young males
Testes tender and pain not eased by elevation
Urgent surgery indicated, contra-lateral testis should also be fixed
Varicocele
Varicosities of pampiniform plexus
Typically occur on left (testicular vein drains into renal vein)
Presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicocele may affect fertility
Management of testicular malignancy
Orchidectomy via inguinal approach
Allows high ligation of testicular vessels
Avoids exposure of another lymphatic field to tumour
Management of testicular torsion
Commonest in young teenagers
Intermittent torsion
Prompt surgical exploration and testicular fixation
Sutures or by placement of testis in a Dartos pouch
Management of varicoceles
Managed conservatively
If concerns about fertility: surgery/ radiology
Management of epididymal cysts
Excised using a scrotal approach
Sclerotherapy
Management of hydrocele
Ligate processus
Inguinal approach
Conditions associated with epididymal cysts
Polycystic kidney disease
CF
VHL syndrome
Hydroceles may develop secondary to:
Epididymo-orchitis
Testicular torsion
Testicular tumours
Acute scrotal disorders in children
Testicular torsion: most common around puberty
Irreducible inguinal hernia: most common in children <2 years old
Epididymitis: rare in prepubescent children
Enuresis
Involuntary urination
Nocturnal enuresis
Bed wetting
Up to 3/4 years
Diurnal enuresis
Inability to control bladder function during the day
Up to 2 years
Primary nocturnal enuresis causes
Variation on normal development (most common)
FH
Overactive bladder
Fluid intake
Failure to wake
Psychological distress
Chronic constipation, UTI, learning disability, cerebral palsy
Overactive bladder pathophysiology
Frequent small volume urination prevents development of bladder capacity
Primary nocturnal enuresis
Management of primary nocturnal enuresis
2 week diary: toileting, fluid intake, bed wetting episodes
History and examination
Reassure if <5
Lifestyle changes: reduce fluid, easy toilet access, pass urine before bed
Encouragement and positive reinforcement
Treat any underlying cause or exacerbating factors, e.g. constipation
Enuresis alarms
Pharmacological treatment
Secondary nocturnal enuresis
Dry for 6 months
Then start bedwetting
Causes of secondary nocturnal enuresis
UTI Constipation TY1 diabetes Maltreatment New psychosocial problems
Diurnal enuresis
Stress incontinence
Urge incontinence
Dry at night
More frequent in girls
Urge incontinence
Overactive bladder
Little warning before emptying
Stress incontinence
Leakage of urine during physical exertion, coughing or laughing
Causes of diurnal enuresis
Recurrent UTI Psychosocial problems Constipation Urge incontinence Stress incontincne
Enuresis alarms
Device that makes a noise at first sign of bed wetting
Wakes child and stops them from urinating
High level of training and commitment
Needs to be used consistently for >3 months
Medication for nocturnal enuresis
Desmopressin: ADH analogue, reduces volume of urine produced by kidneys, taken at bedtime with intention of reducing nocturnal enuresis
Oxybutynin: anticholinergic, reduces contractility of bladder
Imipramine: TCA, relaxes bladder and allows sleep
Cryptorchidism
Congenital absence of one or both testes in the scrotum due to a failure of the testes to descend during development
Epidemiology of cryptorchidism
6% newborns
1.5-3.5% at 3 months
Types of cryptorchidism
True undescended testis: absent from scrotum but lies along the line of testicular descent
Ectopic testis: testis found away from normal path of descent
Ascending testis: secondary ascent out of scrotum
Bilateral: exclude hormonal causes, androgen insensitivity syndrome, disorder of sex development
Pathophysiology of Cryptorchidism
Testis descends from abdomen to scrotum
Pulled by gubernaculum within processus vaginalis
Risk factors for cryptorchidism
Prematurity
Low birth weight
Having other abnormalities of genitalia (hypospadias)
First degree relative with cryptorchidism
Cryptorchidism history
Clarify if testis has even been seen or palpated within scrotum
Newborn check
Parents noticed testicle in scrotum in certain situations (warm bath)
Cryptorchidism examination
Retractile/ normal descended testis
Proceed to palpation to locate testis
Infant/ child laid flat on bed
Palpate along inguinal canal
See if testis can be gently milked down to the base of the scrotum (retractile testis)
If it is pulled down but under tension in the base: high testes
Inguinal undescended testes
Impalpable undescended testes
Ectopic
Intra-abdominal
Absent
Impalpably small
Differential diagnosis undescended testes
Normal retractile testis True undescended testis Ectopic testis Absent testis Bilateral impalpable testis: disordered sexual development, endocrine
Cryptorchidism urgent referral to senior paediatrician within 24hrs
Disordered sexual development
Ambiguous genitalia
Hypospadias
Bilaterally undescended
Access to endocrinology and urology services
Presentation of congenital adrenal hyperplasia and cryptorchidism
Initial management
Risk of salt-losing crisis
Need high-dose NaCl therapy
Careful glucose monitoring
Steroid replacement
Role of imaging in cryptorchidism
No benefit
USS/MRI poor sensitivity
Management of cryptorchidism
At birth
6-8 weeks:
3 months:
Birth: review at 6-8weeks
6-8 weeks: if fully descended no further action, if unilateral re-examine at 3 months
3 months: follow-up if retractile, refer to surgery/urology for definitive intervention if undescended
Examination under anaesthesia, then laparoscopy to locate an impalpable testis
Management cryptorchidism
Palpable testes
Open orchidopexy If 6-12months of age Via groin incision Processus vaginalis and cremasteric covering is separated from cord Testis mobilised and fixed in scrotum
Management of cryptorchidism
Intra-abdominal testes
Single stage or Fowler-Stephens procedure (2 stage procedure)
Testicular vessels ligated, for collateral to come in
Bring testes into scrotum 6 months later
Management of cryptorchidism
Atrophic testis
Remove a trophic testis
Groin exploration if vas/testicular vessels blind-ending or entering deep inguinal ring
Retractile testes
Scrotum-> inguinal canal
Cold or cremasteric reflex
Normal variant
Orchidopexy if fully retract or fail to descend
Surgical complications of undescended testes
Short-term:
Infection
Bleeding
Wound dehiscence
Long-term:
Testicular atrophy
Testicular re-ascent
Complications of an undescended testis
Impaired fertility: too warm
Testicular cancer
Torsion
Testicular torsion
Spermatic cord and its contents twists within tunica vaginalis Compromising blood supply to testicle Surgical emergency 12-25 years old and neonates Will infarct within hours
Pathophysiology of testicular torsion
Mobile testis rotates on the spermatic cord Reduced arterial blood flow Impaired venous return Venous congestion Resultant oedema Infarction to testis if not corrected
Bell-clapper deformity more prone to developing testicular torsion
Bell clapper deformity
Horizontal lie to testes
More prone to developing testicular torsion
Testis lacks normal attachment to tunica vaginalis
More mobile, increasing likelihood of it twisting on cord structures
Neonatal testicular torsion
Attachment between scrotum and tunica vaginalis not full formed
Entire testis and tunica vaginalis can tort
Extra-vaginal torsion
Can occur in-utero
Risk factors for testicular torsion
12-25 age
Previous torsion
FH
Undescended testes
Clinical features of testicular torsion
Sudden onset severe unilateral testicular pain
Associated with nausea and vomiting, secondary to the pain
Referred abdominal pain
High position with horizontal lie
Swollen and tender
Cremasteric reflex absent
Pain continues despite elevation (negative Prehn’s sign)
DD of testicular torsion
Epididymo-orchitis Trauma Inguinal hernia Testicular cancer Renal colic Hydrocele Idiopathic scrotal oedema Torsion of the hydatid of Morgagni
Torsion of the Hydratid of Morgagni
R4emnant of Müllerian duct
Common testicular appendage
Common in younger age group
Scrotum usually less erythematous with a normal lie of the testis
Blue dot may be present in the upper half of the hemi scrotum
Visible infarcted hydatid
Investigations of testicular torsion
Clinical diagnosis
Straight to theatre for scrotal exploration
Doppler US: investigate potential compromised blood flow to testis
Urine dipstick
Management of testicular torsion
Surgical emergency
4-6hr window to salvage testes
Urgent surgical exploration
Strong analgesia and anti-emetics, NBM, IV fluids
Fix both testes to scrotum
Bilateral orchidopexy
If non-viable: orchidectomy and prosthesis can be inserted
Complications of testicular torsion
Testicular infarction
Atrophy of affected testicle
After scrotal exploration: Chronic pain Palpable suture Risk to future fertility Theoretical risk of future torsion despite fixation
Epididymitis
Inflammation of epididymis
15-30 and >60years
Pathophysiology of epididymo-orchitis
Local extension of infection
From LUT: bladder and urethra
Via enteric: classic UTI
Or non-enteric: STI
Epididymo-orchitis in <35 organisms
Sexual transmission
N.gonorrhoea
C.trachomatis
Epididymo-orchitis in >35 organisms
Enteric organism from a urinary tract infection E.coli Proteus spp Klebsiella pneumonia Pseudomonas aeruginosa
Bladder outflow obstruction from prostatic enlargement
Retrograde ascent of pathogen
Mumps orchitis
Post-pubertal boys after mumps viral infection
Unilateral or bilateral orchitis
Accompanied with a fever, around 4-8 days after onset of mumps parotitis
Disease self-resolves within a week with supportive management
Complications of mumps orchitis
Testicular atrophy
Infertility
Management of mumps orchitis
Mumps IgM/IgG serology
Notifiable disease
Inform local health protection team if suspicion
Risk factors for epididymo-orchitis
Depends on mechanism of disease: STI/UTI
Non-enteric causes: MSM, multiple sexual partners, known contact of gonorrhea
Enteric causes: recent instrumentation or catheterisation, BOO, immunocompromised state
Clinical features of epididymo-orchitis
Unilateral scrotal pain and swelling
Fever and rigors
Dysuria, storage LUTS, urethral discharge
Red and swollen
Tender on palpation
Associated hydrocele
Prehn’s sign positive
DD of epididymo-orchitis
Testicular torsion Testicular trauma Testicular abscess Epididymal cyst Hydrocele Testicular tumour
Epididymo-orchitis investigations
Urine dipstick Mc&S Collect first-void urine Send urine for NAAT: N.gonorrhoeae, C.trachomatis, M.genitalium STI screen FBC, CRP Bloo cultures USS Doppler for testicular blood flow
Initial management of epididymitis
Outpatient Ax Analgesia Enteric: ofloxacin STI: ceftriaxone and doxycycline
Complications of epididymitis
Reactive hydrocele
Abscess
Testicular infarction
Hypospadias
Urethral meatus located at abnormal site
Usually on underside of the penis
Pathophysiology of hypospadias
Arrest of penile development
Hypoplasia of ventral tissue of the penis
Clinical features of hypospadias
Abnormal urinary flow
Abnormal penile curvature during erections
Ventral opening of urethral meatus
Ventral curvature of penis or ‘Chordee’
Dorsal hooded foreskin
Classification of hypospadias
Glandular Coronal Shaft Scrotal Perineal
Differential diagnosis of hypospadias
Disorders of sexual development
Congenital adrenal hyperplasia
Investigations to rule out DSD
Disorder of sex development
Detailed history and examination Karyotype Pelvis US scan Urea and electrolytes Endocrine hormones: testosterone, 17 alpha-hydroxyprogesterone LH FSH ACTH Renin Aldosterone
Management of hypospadias
Urethroplasty with graft from foreskin (advise against circumcision)
Aims of urethroplasty in hypospadias
Bringing the meatus to the glans of the penis
Chordee is corrected to straighten the penis
Dorsal foreskin is managed with either circumcision or reconstruction, depending on anatomy, parental and surgical preference
Short term complications of hypospadias
Post surgical catheter may block, become displaced or kinked
Urethral catheter may cause pain and bladder spasms (Give oxybutynin)
Bleeding
Infection
Long term complications of hypospadias
Urethral fistula
Risks of mental or urethral stenosis
Complications of untreated BXO
Meatal stenosis
Phimosis
Erosions of glans and prepuce which can extend to urethra
Surgical complications of BXO
Swelling
Serous discharg around penis for a week
Infection
Management of BXO
Circumcision
Send foreskin off to histopathology
Balanitis xerotica obliterans
Keratinisation of tip of foreskin causes scarring
Prepuce remains non-retractile
Clinical features of BXO
Ballooning of foreskin during micturition Self-resolving as prepuce becomes more mobile with age, normal age 2-4 Scarring of urethral meatus Irritation Dysuria Haematuria Local infecton Urinary obstruction
Examination of BXO
White, fibrotic and scarred prep UTi all tip
Difficult to visualise meatus
